Hello, my name is Cliff Willeman from Children's Health Care of Atlanta, and I would like to provide a brief overview of arthroscopic treatment of osteochondral lesions of the talus. OLTs occur in 4% of all osteochondral lesions and can occur in 2 to 6% of ankle sprains. These are present in 23% of those undergoing surgical treatment for chronic ankle instability in the adult population. In the pediatric population, the most common age range is from 12 to 19 years and occurs more commonly in females. OLTs are present in the medial side, less commonly associated with trauma, but are characterized as being slightly more posterior and deeper, but may occur dramatically in plantar flexion, inversion, and external rotation combination injuries. In contrast, the lateral lesions are slightly more anterior, shallower, and are more commonly related to trauma. These injuries have been recreated with a combination of movements in the lab with dorsiflexion, inversion, and internal rotation. Don't forget that all ankle pain and radiographic signs of the OLT represent symptomatic OLTs. There are certainly lots of other sources of ankle pain in adolescent athletes, including interlateral synovial impingement, anterior bony impingement, occult navicular fractures, lateral instability, tarsal coalitions, perineal tendon pathology, other tendinopathies, and subtalar pathology. So thorough exam and evaluation is critical. Classic imaging studies include planar radiographs and MRI. AP lateral motor views are standard, but plantar flexion AP views are helpful, much like a notch radiograph in the knee for viewing an OCD of the medial femoral condyle is helpful for posterior medial OLTs as the plantar flexion delivers the more posteriorly located lesion into a tangential view for the x-ray beam. Lateral maximal dorsiflexion or plantar flexion views also may aid in preoperative planning if you're trying to decide whether an anterior only or a posterior approach is needed. MRI has certainly been shown to accurately predict fragment stability compared to arthroscopic findings, as we have shown. OCD treatment varies, but it's important to note that non-operative treatment of stable lesions has been shown to be reliable, although radiographic outcomes do not always correlate. A bit about arthroscopy. Traction in a static mode is rarely needed, as adolescents are typically ligamentously lax relative to adults, and you're working really more in the recesses of the joints versus the central aspect of the joint. I do find dynamic traction useful, and I use a setup similar to that shown in the right middle picture here. My partner, Mike Bush, has popularized the use of coaxial portals. This is a schematic showing conventional posterior ankle portals straddling the Achilles tendon, which can place you close to the posterior tibial artery and nerve. Out of necessity, Mike used coaxial portals in the era when the treatment of hemophiliac patients was not as advanced, and very commonly synovectomy was being performed in these challenging cases using coaxial portals allows him to tremendously access his joints more easily and safely, and hence his description of these portals, which also are useful for accessing posterior medial LLTs. This is a bit what it looks like clinically. Retroarticular drilling is certainly a useful treatment. It's not as commonly used because these patients often present with more advanced lesions, but in that case of a patient that has a persistent OLT that's symptomatic does not improve with non-operative treatment, retroarticular drilling can be performed. There's a variable angle drill guide that moves in two planes that can be useful for accessing these lesions, as well as using a three by three parallel guide that on one end is cannulated for 0.45 drill pins versus 0.062 on the other end, depending on the size of the lesion. You can also augment these lesions with retroarticular bone grafting as needed. This technique is associated with improvements in PRO scores as well. Bone grafting techniques are variable. You can harvest from the iliac crest using trefines, and here you can see the cartilage cap is trimmed, and then you can insert it in a cannulated fashion. Debridement and marrow stimulation still remains the workhorse of ankle arthrospy for the treatment of OLT lesions in the pediatric adolescent patients. It's typically reserved for the unsalvageable lesion that's less than one and a half centimeter square. Posterior portals are useful for posterior medial lesions, and you can certainly augment this with bone graft from autologous or allograft sources in the deeper lesions. Overall outcomes have shown few treatment failures, and the lesions are small, much like in microfracture in other joints. Overall with good to excellent subjective outcomes in 60 to 80 percent of patients. You can also do single-stage cartilage restoration or microfracture plus type treatments. The most commonly used is biocartilage, as an example, is a dehydrated allograft cartilage paste that can be injected into the defect site and then sealed with fiber and glue. In deeper lesions, you can use local autograft from the calcaneus or harvest from the iliac crest or even distal tibia to help address bone loss before inserting the allograft chondral paste and sealing with fiber and glue. So how do these patients do? The Boston Children's has reported the largest series of over 100 ankles in 100 patients over 10 years. The mean age of their patients was 14.3 years, with a fairly wide range of 7 to 18-year-olds. Their mean fall was 3.3 years. Majorities were medial lesions in 80 percent of cases. They had a variety of treatments, as you would imagine, depending on the stage of the lesion. Female gender and BMI over 30 tended to have poor outcome scores. And they found, as shown elsewhere, that radiographic appearance did not correlate with clinical outcome. 16 percent of those show fully healed lesions radiographically, although 64 percent of patients reported improvement. Overall, we must be careful when operating on this group of patients because a guaranteed success is not the case. In their series, 49 percent of patients had good outcomes based on Burton-Hardy clinical grade, 21 percent fair, but 30 percent poor. 82 percent of patients were satisfied and approximately the same amount returned to play at six months. But don't lose sight of these patients as almost a third underwent revision, just less than two years. So key points with OLTs. The treatment is determined by the cartilage status, as we do elsewhere in other joints. With intact lesions treated with drilling, augmented with grafting if needed, if the cartilage is non-intact and smaller, then debridement and marrow stimulation in larger lesions can be augmented with chondral products and or bone grafting, or certainly in the larger lesions, open approaches for osteochondral transplantation. Be familiar with establishing posterior portals for posterior medial lesions, as even with maximal dorsiflexion traction and angled instruments, sometimes full access is not possible in these lesions. And then children rarely require osteochondral grafts, and it's certainly contraindicated in open physes that would not permit an osteotomy for access. Marrow stimulation still remains the most common arthroscopic treatment with overall good outcomes. Thank you.

arthroscopic treatment

osteochondral lesions

talus

OLTs

ankle sprains